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Practice Guideline
. 2024 Jun 18;83(24):2497-2604.
doi: 10.1016/j.jacc.2024.02.013. Epub 2024 May 14.

2024 ACC/AHA/AACVPR/APMA/ABC/SCAI/SVM/SVN/SVS/SIR/VESS Guideline for the Management of Lower Extremity Peripheral Artery Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

Writing Committee Members; Heather L Gornik, Herbert D Aronow, Philip P Goodney, Shipra Arya, Luke Packard Brewster, Lori Byrd, Venita Chandra, Douglas E Drachman, Jennifer M Eaves, Jonathan K Ehrman, John N Evans, Thomas S D Getchius, J Antonio Gutiérrez, Beau M Hawkins, Connie N Hess, Karen J Ho, W Schuyler Jones, Esther S H Kim, Scott Kinlay, Lee Kirksey, Debra Kohlman-Trigoboff, Chandler A Long, Amy West Pollak, Saher S Sabri, Lawrence B Sadwin, Eric A Secemsky, Maya Serhal, Mehdi H Shishehbor, Diane Treat-Jacobson, Luke R Wilkins
Practice Guideline

2024 ACC/AHA/AACVPR/APMA/ABC/SCAI/SVM/SVN/SVS/SIR/VESS Guideline for the Management of Lower Extremity Peripheral Artery Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

Writing Committee Members et al. J Am Coll Cardiol. .

Abstract

Aim: The "2024 ACC/AHA/AACVPR/APMA/ABC/SCAI/SVM/SVN/SVS/SIR/VESS Guideline for the Management of Lower Extremity Peripheral Artery Disease" provides recommendations to guide clinicians in the treatment of patients with lower extremity peripheral artery disease across its multiple clinical presentation subsets (ie, asymptomatic, chronic symptomatic, chronic limb-threatening ischemia, and acute limb ischemia).

Methods: A comprehensive literature search was conducted from October 2020 to June 2022, encompassing studies, reviews, and other evidence conducted on human subjects that was published in English from PubMed, EMBASE, the Cochrane Library, CINHL Complete, and other selected databases relevant to this guideline. Additional relevant studies, published through May 2023 during the peer review process, were also considered by the writing committee and added to the evidence tables where appropriate.

Structure: Recommendations from the "2016 AHA/ACC Guideline on the Management of Patients With Lower Extremity Peripheral Artery Disease" have been updated with new evidence to guide clinicians. In addition, new recommendations addressing comprehensive care for patients with peripheral artery disease have been developed.

Keywords: ACC/AHA Clinical Practice Guidelines; acute limb ischemia; angioplasty; ankle-brachial index; anticoagulation therapy; antiplatelet therapy; antithrombotic therapy; atherosclerosis; atypical leg symptoms; blood pressure lowering; bypass graft/bypass grafting/surgical bypass; cilostazol; claudication/intermittent claudication; critical limb ischemia/chronic limb-threatening ischemia; diabetes; diagnostic testing; endovascular therapy; exercise rehabilitation/exercise therapy/exercise training/supervised exercise; foot care; hybrid approach; lipid lowering; lower extremity/foot wound/ulcer; medical management; open revascularization; percutaneous therapy; peripheral artery disease/peripheral arterial disease/peripheral vascular disease/lower extremity arterial disease; smoking/smoking cessation; statin; stenting; thrombolysis; vascular intervention; vascular surgery.

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Figures

FIGURE 1
FIGURE 1. Clinical Subsets of PAD
ALI indicates acute limb ischemia; CLTI, chronic limb-threatening ischemia; and PAD, peripheral artery disease.
FIGURE 2
FIGURE 2. Algorithm for Diagnostic Testing for PAD
*If not already performed. Colors correspond to Table 3. ABI indicates ankle-brachial index; CLTI, chronic limb-threatening ischemia; CTA, computed tomography angiography; GDMT, guideline-directed management and therapy; MRA, magnetic resonance angiography; PAD, peripheral artery disease; PVR, pulse volume recording, SPP, skin perfusion pressure; TBI, toe-brachial index; and TcPO2, transcutaneous oxygen pressure.
FIGURE 3
FIGURE 3. Health Disparities and PAD-Related Risk Amplifiers Increase Risk of MACE and MALE
MACE indicates major adverse cardiovascular events; MALE, major adverse limb events; and PAD, peripheral artery disease.
FIGURE 4
FIGURE 4. Medical Therapy and Foot Care for PAD
Colors correspond to Table 3. Afib indicates atrial fibrillation; BID, 2 times daily; CLTI, chronic limb-threatening ischemia; DAPT, dual antiplatelet therapy; PAD, peripheral artery disease; SAPT, single antiplatelet therapy; SARS-CoV-2, severe acute respiratory syndrome coronavirus 2; and VTE, venous thromboembolism.
FIGURE 5
FIGURE 5. Algorithm for Revascularization for Claudication (Chronic Symptomatic PAD)
Colors correspond to Table 3. GDMT indicates guideline-directed management and therapy; PAD, peripheral artery disease; and QOL, quality of life.
FIGURE 6
FIGURE 6. Components of Care for CLTI
CLTI indicates chronic limb-threatening ischemia.
FIGURE 7
FIGURE 7. Algorithm for Management of CLTI
Colors correspond to Table 3. CLTI indicates chronic limb-threatening ischemia, GDMT, guideline-directed management and therapy; PAD, peripheral artery disease; and QOL, quality of life.
FIGURE 8
FIGURE 8. Algorithm for Diagnosis and Management of ALI
Colors correspond to Table 3. ALI indicates acute limb ischemia; CV, cardiovascular; and ECG, electrocardiogram.
See this image and copyright information in PMC

References

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Imaging for PAD

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Female Sex

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Antiplatelet and Antithrombotic Therapy for PAD

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Lipid-Lowering Therapy for PAD

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Antihypertensive Therapy for PAD

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Smoking Cessation for PAD

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Diabetes Management for PAD

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OtherMedical Therapies for Cardiovascular Risk Reduction in PAD

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Medication for Leg Symptoms in Chronic Symptomatic PAD

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Preventive Foot Care for PAD

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Exercise Therapy for PAD

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Revascularization for Asymptomatic PAD

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Revascularization Techniques and Registries for Chronic Symptomatic PAD and CLTI

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Revascularization for Claudication

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Conduit for Surgical Revascularization for Femoropopliteal Disease

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Team-Based Care for CLTI

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Revascularization for CLTI

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    1. Piazza M, Ricotta JJ 2nd, Bower TC, et al. Iliac artery stenting combined with open femoral endarterectomy is as effective as open surgical reconstruction for severe iliac and common femoral occlusive disease. J Vasc Surg. 2011;54:402–411. - PubMed
    1. Starodubtsev V, Karpenko A, Ignatenko P. Hybrid and open surgery of Trans-Atlantic Inter-Society II type C and D iliac occlusive disease and concomitant lesion of common femoral artery. Int Angiol. 2016;35:484–491. - PubMed

Pressure Offloading for CLTI

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Wound Care and Management of Infection for CLTI

    1. Garcia-Morales E, Lázaro-Martínez JL, Aragón-Sánchez J, et al. Surgical complications associated with primary closure in patients with diabetic foot osteomyelitis. Diabet Foot Ankle. 2012;3. 10.3402/dfa.v3i0.19000 - DOI - PMC - PubMed
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Approach to the “No Option” Patient With CLTI

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Amputation for CLTI

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Acute Limb Ischemia

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Initial Clinical Evaluation and Diagnostic Approach to ALI

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Revascularization for ALI

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Adjunctive Therapies to Minimize Tissue Loss in ALI

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Anticoagulation for ALI

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Diagnostic Evaluation for the Cause of ALI

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    1. Morris-Stiff G, D’Souza J, Raman S, et al. Update experience of surgery for acute limb ischaemia in a district general hospital–are we getting any better? Ann R Coll Surg Engl. 2009;91:637–640. - PMC - PubMed
    1. Landry GJ, Shukla R, Rahman A, et al. Demographic and echocardiographic predictors of anatomic site and outcomes of surgical interventions for cardiogenic limb emboli. Vasc Med. 2016;21:528–534. - PubMed
    1. Creager MA, Kaufman JA, Conte MS. Clinical practice. Acute limb ischemia. N Engl J Med. 2012;366:2198–2206. - PubMed

Longitudinal Follow-Up of PAD

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    1. Treat-Jacobson D, Lindquist RA, Witt DR, et al. The PADQOL: development and validation of a PAD-specific quality of life questionnaire. Vasc Med. 2012;17:405–415. - PubMed
    1. Kim BH, Cho KI, Spertus J, et al. Peripheral artery questionnaire improves ankle brachial index screening in symptomatic patients with peripheral artery disease. Int J Clin Pract. 2014;68:1488–1495. - PubMed
    1. Noyes AM, Abbott JD, Gosch K, et al. Association between health status and sociodemographic, clinical and treatment disparities in the Patient-centered Outcomes Related to TReatment Practices in Peripheral Arterial Disease: Investigating Trajectories (PORTRAIT) registry. Vasc Med. 2018;23:32–38. - PubMed
    1. Hammad TA, Smolderen KG, Spertus JA, et al. Associations of exercise ankle-brachial index, pain-free walking distance and maximum walking distance with the Peripheral Artery Questionnaire: finding from the PORTRAIT PAD Registry. Vasc Med. 2019;24:32–40. - PubMed

Advocacy Priorities

    1. American Heart Association. PAD national action plan. 2022. Accessed June 7, 2023. https://professional.heart.org/-/media/PHD-Files-2/Science-News/p/PAD-Na...
    1. Creager MA, Matsushita K, Arya S, et al. Reducing nontraumatic lower-extremity amputations by 20% by 2030: time to get to our feet: a policy statement from the American Heart Association. Circulation. 2021;143:e875–e891. - PubMed

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